Citation Nr: 0716933
Decision Date: 06/07/07 Archive Date: 06/18/07
DOCKET NO. 05-12 062 ) DATE
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On appeal from the
Department of Veterans Affairs Regional Office in San Diego,
California
THE ISSUE
Entitlement to service connection for a psychiatric disorder,
to include post-traumatic stress disorder (PTSD).
REPRESENTATION
Appellant represented by: Disabled American Veterans
ATTORNEY FOR THE BOARD
Joseph R. Keselyak, Associate Counsel
INTRODUCTION
The veteran served on active duty from August 1991 to August
1994 and from May 1997 to February 1998.
This matter comes to the Board of Veterans' Appeals (Board)
from a June 2004 rating decision of the Department of
Veterans Affairs (VA) Regional Office (RO) in San Diego,
California, which denied the veteran's claim of entitlement
to service connection for PTSD.
The Board notes that, on her Substantive Appeal, the veteran
requested a Board hearing, but later withdrew that request.
Accordingly, adjudication of the present appeal is
appropriate.
The appeal is REMANDED to the RO via the Appeals Management
Center (AMC), in Washington, DC. VA will notify the
appellant if further action is required.
REMAND
The veteran is claiming that she has PTSD due to an in-
service sexual assault. Specifically, the veteran alleges
that she was drugged and raped in March 1993. The Board
notes that the veteran's service medical records contain a
November 1993 medical record that contains complaints of
sexual assault and contains a diagnosis of traumatic vaginal
laceration.
Following her discharge from service in February 1998, the
veteran first sought treatment for alcohol abuse from Tampa
General Hospital in August 1999. Following this period of
treatment, she also sought treatment for alcohol abuse from
the Kendall Hospital in July 2002 and ultimately Volunteers
of America (VOA) from October to November 2002.
In November 2002, the veteran was discharged from the care of
VOA and sought treatment for alcohol and amphetamine
dependence from VA. Numerous psychological evaluations
following her admission to the VA hospital contain diagnoses
of alcohol dependence and amphetamine dependence in full
sustained remission. A July 2004 Vet Center psychiatric
report contains a diagnosis of anxiety disorder not otherwise
specified, "rule out" PTSD and alcohol dependence in
sustained remission. An April 2005 letter from a Vet Center
psychiatrist does not diagnose PTSD, but appears to relate
the veteran's psychiatric problems, including anxiety, to in-
service sexual assault.
VA's duties under the VCAA include providing a medical
examination or obtaining a medical opinion when such is
necessary to make a decision on the claim. 38 U.S.C.A. §
5103A(d) (West 2002 & Supp. 2006); 38 C.F.R. § 3.159(c)(4)
(2006). Upon consideration of the evidence outlined above,
the Board finds that a medical examination is necessary to
decide the claim on appeal. In particular, an examination is
necessary to determine the nature of the veteran's
psychiatric disorder and any possible relationship thereof to
documented in-service sexual assault. Notably, the July 2004
Vet Center psychiatric report suggests that continued
evaluation is needed to determine the presence or absence of
PTSD.
Accordingly, the case is REMANDED for the following action:
1. Send the veteran a corrective VCAA
notice under 38 U.S.C.A. § 5103(a) and 38
C.F.R. § 3.159(b), that includes an
explanation as to the information and
evidence needed to establish a disability
rating and effective date for the claim on
appeal, as outlined by the Court in
Dingess/Hartman v. Nicholson, 19 Vet. App.
473 (2006).
2. Thereafter, the RO should forward the
claims folder to a VA psychiatrist for the
purpose of obtaining an opinion regarding
the extent and etiology of any psychiatric
disorder that the veteran might have,
including PTSD. The physician should
provide an opinion, in accordance with the
DSM-IV, as to whether it is at least as
likely as not that the veteran has PTSD,
or any other psychiatric disorder, related
to the veteran's in-service sexual
assault.
3. When the development requested has
been completed, the claim on appeal should
again be adjudicated on the basis of the
additional evidence. If the benefits
sought are not granted, the appellant
should be furnished a Supplemental
Statement of the Case, and afforded a
reasonable opportunity to respond before
the record is returned to the Board for
further review.
The appellant has the right to submit additional evidence and
argument on the matter or matters the Board has remanded.
Kutscherousky v. West, 12 Vet. App. 369 (1999).
This claim must be afforded expeditious treatment. The law
requires that all claims that are remanded by the Board of
Veterans' Appeals or by the United States Court of Appeals
for Veterans Claims for additional development or other
appropriate action must be handled in an expeditious manner.
See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2006).
_________________________________________________
JAMES L. MARCH
Veterans Law Judge, Board of Veterans' Appeals
Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Appeals for Veterans Claims. This remand is in the
nature of a preliminary order and does not constitute a
decision of the Board on the merits of your appeal.
38 C.F.R. § 20.1100(b) (2006).